In a February 4th article, the Wall Street Journal reported that Hospitals are exploring house calls as a method to cut costs and admissions. The article cites that “in addition to a number of doctors treating frail patients at home, insurers and health systems are sending teams of doctors, nurses, physician assistants and pharmacist into homes to monitor patients, administer treatment and ensure that medications are being taken properly.” In large part, the aim is to avoid new financial penalties from the Center for Medicare & Medicaid Services. (In October, the federal government began withholding payments to hospitals with higher than predicted readmission rates for certain patients).
"People may think of the house call as this quaint idea of a doctor heading out in his horse and buggy, but it is an excellent and necessary model for taking care of vulnerable high-cost patients," says Bruce Leff, a professor of medicine at Johns Hopkins University School of Medicine who developed the Hospital at Home model and is president of the American Academy of Home Care Physicians. The strategy echoes a 2012 study by the Journal of the American Board of Family Medicine entitled “Trends in Physician House Calls to Medicare Beneficiaries”. The study examined house calls made in 2000, 2003 and 2006 and concluded that during the 6 years examined, the number of physician house calls to Medicare beneficiaries more than doubled, while the number of physicians making the house calls declined.
The study further explains that conditions are ripe for a resurgence of the ‘vanishing practice’. “Recent policy and demographic trends and the changing health care landscape have created an environment favorable for house calls to re-emerge as a viable health care delivery model for frail and functionally limited elderly patients. […] The human and financial costs of frequent hospitalization [...] has reemphasized the patient's home as a viable site of health care delivery. New mobile diagnostic and information technologies support the practice of medicine in the home in ways previously not possible. Further, the Patient Protection and Affordable Care Act contains several measures that support more physician involvement in home care. Most notably, the Independence at Home Act was included as a demonstration project that develops a new model of funding physician-led, home-based primary care, with implementation scheduled in 2012.”
Despite that the environment is favorable, is there indeed an increasing trend in home visit? News reports from Austin, to San Francisco seem to be highlighting the movement, though causes range from hospitals looking to curtail costs to philanthropic programs such as the UCSF House Calls Program. A coinciding trend might be the merge of home health agencies and the physician practice - a move that could become more common under health system reform. As one example, Home Visit Doctors - a two physician house call practice in Philadelphia, was recently acquired by the Visiting Nurses Association of Greater Philadelphia (VNA of Greater Philadelphia). According to the CEO of VNA of Greater Philadelphia, “I believe that home health care and primary health care is a marriage made in heaven.” 1 For the home health agency, it is a sweet deal. Having a physician on staff provides the potential ability to test, diagnose and prescribe treatment in the home. Moreover, the agency may benefit from an additional strategy – it can improve its ability to implement aspects of health system reform. For example, the VNA of Greater Philadelphia can more easily meet CMS requirements for Medicare beneficiaries receiving home-based care to have faced-to-face encounters with physicians no more than 90 days before or within 30 days after initiating service.
Physicians generally refer to home health agencies; becoming employed by one is very atypical, but in this situation, the employed physicians get additional financial stability and can practice doing what they enjoy most. The two doctors who now work with the Visting Nurses Association have made their practice more viable, with a substantial increase in the number of house calls paid by Medicare. (Of note – patients who receive home healthcare are not required to get medical care from an agency’s physician staff).
Statistics broadcast from the American Academy of Home Care Physicians are encouraging. According to the academy, the clinical service and financial benefits that home based primary care practice can provide to ACO’s is undeniable. “The cost of homecare is significantly lower when compared to hospital visits, emergency room procedures, or ambulance transportation. Care management systems including house calls have demonstrated the ability to reduce hospital and ER admissions and re-admissions, average lengths of stay, and to reduce nursing home admissions.” 2
It may be difficult at the moment to predict the trend – but if cost drivers are any indication, the term “medical home” could take on a whole new meaning.
1. Stagg Elliot, Victoia (2012. Aug. 27). American Medical News. (2012. Aug, 27). “Home health agency acquires physician practice”. American Medical News. http://www.ama-assn.org/amednews/2012/08/27/bisb0827.htm
2 Kunins, H; Mohamed, A; Wajnberg, A; Wang, K; (2010). Hospitalizations and Skilled Nursing Facility Admissions Before and After the Implementation of a Home-Based Primary Care Program. Journal of the American Geriatric Society. http://www.aahcp.org/associations/11307/files/hospitalization_and_SNF_admissions_before_and_after_house_call.pdf
Wall Street Journal, (2013, Feb. 4). Hospitals Try House Calls to Cut Costs, Admissions. http://online.wsj.com/article/SB10001424127887324610504578278102547802848.html
Kim Mulvihill, MD.(2012. April 27). Doctors’ House Calls Making A Comeback In San Francisco. (KCBS-5. HealthWatch. http://sanfrancisco.cbslocal.com/2012/04/27/healthwatch-doctors-house-calls-making-a-comeback-in-san-francisco/
Patrick Beach (2012.Sept. 16). Doctor House Calls on the Rise. The Statesman.com http://www.statesman.com/news/news/local/doctor-house-calls-on-the-rise/nSLRY/
J Am Board Fam. Med. 2012;25(6):862-868. Trends in Physician House Calls to Medicare Beneficiaries. Lars E. Peterson, MD, PhD, Steven H. Landers, MD, MPH, Andrew Bazemore, MD, MPH http://www.medscape.com/viewarticle/774524
Unwin, Brian K; Tatum, Paul E. (2011. April 15). House Calls. Amerian Family Physician. http://www.aafp.org/afp/2011/0415/p925.html
The UCSF House-call Program - http://geriatrics.ucsf.edu/care/housecalls.htmlAmerican Academy of Home Care Physicians - http://www.aahcp.org/
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